báo cáo khoa học: "Perceptions of short-term medical volunteer work: a qualitative study in Guatemala" pptx

BioMed Central
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Globalization and Health
Open Access
Research
Perceptions of short-term medical volunteer work: a qualitative
study in Guatemala
Tyler Green
1
, Heidi Green
1
, Jean Scandlyn*
2
and Andrew Kestler
3
Address:
1
School of Medicine, University of Colorado Denver, Denver, Colorado, USA,
2
Departments of Anthropology and Health and Behavioral
Sciences, University of Colorado Denver, Denver, Colorado, USA and
3
Division of Emergency Medicine, University of Colorado Denver, Denver,
Colorado, USA
Email: Tyler Green - ; Heidi Green - ; Jean Scandlyn* - ;
Andrew Kestler -
* Corresponding author
Abstract
Background: Each year medical providers from wealthy countries participate in short-term medical
volunteer work in resource-poor countries. Various authors have raised concern that such work has the

potential to be harmful to recipient communities; however, the social science and medical literature
contains little research into the perceptions of short-term medical volunteer work from the perspective
of members of recipient communities. This exploratory study examines the perception of short-term
medical volunteer work in Guatemala among groups of actors affected by or participating in these
programs.
Methods: The researchers conducted in-depth, semi-structured interviews with 72 individuals, including
Guatemalan healthcare providers and health authorities, foreign medical providers, non-medical personnel
working on health projects, and Guatemalan parents of children treated by a short-term volunteer group.
Detailed notes and summaries of these interviews were uploaded, coded and annotated using Atlas.ti
(Scientific Software Development GmbH, Berlin) to identify recurrent themes from the interviews.
Results: Informants commonly identified a need for increased access to medical services in Guatemala,
and many believed that short-term medical volunteers are in a position to offer improved access to
medical care in the communities where they serve. Informants most frequently cited appropriate patient
selection and attention to payment systems as the best means to avoid creating dependence on foreign
aid. The most frequent suggestion to improve short-term medical volunteer work was coordination with
and respect for local Guatemalan healthcare providers and their communities, as insufficient understanding
of the country's existing healthcare resources and needs may result in perceived harm to the recipient
community.
Conclusion: The perceived impact of short-term medical volunteer projects in Guatemala is highly
variable and dependent upon the individual project. In this exploratory study, project characteristics were
identified that are consistently perceived to be either positive or negative. These findings have direct
implications for anyone involved in the planning and execution of short-term medical volunteer projects,
including local and foreign medical team members, project planners and coordinators, and health
authorities. Most importantly, this preliminary study suggests avenues for future study and evaluation of
the impact of short-term medical volunteer programs on local health care services.
Published: 26 February 2009
Globalization and Health 2009, 5:4 doi:10.1186/1744-8603-5-4
Received: 12 June 2008
Accepted: 26 February 2009
This article is available from: />© 2009 Green et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( />),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Background
There is growing interest among healthcare providers in
the field of global health; over 25% of all 2008 United
States (US) medical school graduates participated in glo-
bal health experiences during medical school. Beyond
medical school, there are countless opportunities for phy-
sicians to volunteer their services abroad in resource poor
countries, frequently in the form of medical missions that
last for a week or two at a time. Several editorials in the
medical and social sciences literature have raised impor-
tant questions about potential unintended consequences
of such short-term medical volunteer work [1-9]. Editori-
als such as these raise concern about the ability of short-
term volunteers to provide safe and effective medical serv-
ices in the setting of language and cultural barriers that
impair clear communication between patients and health-
care providers. They also raise concerns about a lack of fol-
low-up care for patients who receive treatment from
groups with a short-term presence. They raise ethical con-
cerns about people without formal medical training par-
ticipating in these groups, or medical professionals
practicing beyond the scope of their expertise and practice
at home, in a setting where they are not held accountable
for the consequences of medical interventions made. In
addition to basic questions pertaining to patient safety,
these editorials raise important questions about the

impact of short-term medical missions on the larger med-
ical systems in the countries they visit. For example, it is
suggested that short-term medical groups that are not
integrated with local medical systems do not understand
local medical needs, and consequently, their efforts will
be misguided. Furthermore, there is suggestion that
groups providing free medical care in other countries
undermine the livelihood of medical providers who
depend on payment from patients in those countries. The
literature in medical anthropology is filled with examples
of unintended consequences of medical programs that
pay insufficient attention to local conditions and culture
and, perhaps more importantly, fail to consider the poten-
tially incompatible and harmful cultural assumptions and
values embedded in those programs [10,11]. With count-
less groups from wealthy countries participating in short-
term medical volunteer work abroad, it is critical that we
evaluate the safety and effectiveness of these interventions
for patients, as well as the larger implications and conse-
quences of such work on the development of medical sys-
tems and the health of communities where this work takes
place. The editorials summarized above were written by
medical professionals from wealthy countries with an
interest in global health, and these writings serve as an
important starting point in this discussion. Even more
important, however, are the opinions and perspectives of
those who live and work in the countries where this work
takes place, and thus far, their voices have not been heard.
The aim of this study is to expand the critical discussion of
short-term medical volunteer work by giving voice to the

perceptions of a variety of persons who are involved in,
work alongside, or are affected by short-term medical vol-
unteer programs. Because of its geographic proximity to
the US and its natural resource base, the US has long-
standing political and economic interests in Guatemala.
Short-term medical volunteer work may be seen as one
extension of those interests in the post-colonial era. As
such, short-term medical volunteers often bring with
them, albeit unconsciously, attitudes that foster depend-
ence and lack respect for local practitioners and local
knowledge and practices related to health. Understanding
how short-term medical volunteer work is perceived by
those living and working in receiving communities is a
critical first step in designing and implementing health-
care programs that provide needed healthcare services to
supplement and complement local healthcare systems
without undermining their efforts. Specifically, we sought
to explore the perceived utility and perceived impact (pos-
itive and negative) of short-term medical volunteer work
in Guatemala from the perspective of healthcare providers
and health authorities in Guatemala. Because of the short
time available for the research, this study focuses on the
perceptions of these individuals and not on the impact of
short-term volunteer programs. Its purpose is to identify
and describe the range of perceived issues surrounding
short-term medical volunteer work as a basis for future in-
depth studies.
We begin with a brief description of the Guatemalan
healthcare systems and key health outcomes to provide
the reader with an understanding of the context in which

short-term medical volunteer programs operate. This is
followed by a description of our research methods and
findings and a discussion of short-term medical volunteer
programs in the context of international aid and develop-
ment to contextualize the themes identified herein. It is
hoped that this report will stimulate further investigation
into the specific topics raised within this report.
Healthcare and Health Outcomes in Guatemala
To understand the perceptions of healthcare providers,
healthcare authorities and others working with short-term
volunteers in Guatemala, it is important to recognize the
provision of healthcare services in Guatemala and health
status of the Guatemalan population based on leading
health indicators. In 2007, Guatemala's per capita gross
domestic product (GDP) was $5,400 US dollars (USD) in
purchasing power parity [12], which is 130
th
out of 228
countries ranked, making Guatemala a "middle income"
country on a macroeconomic level. Nevertheless, the
income gap between the Guatemalan rich and poor con-
tinues to be enormous: 51% of Guatemalans live on less
than approximately $2 USD per day and 15% of Guate-
Globalization and Health 2009, 5:4 />Page 3 of 13
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malans live on less than approximately $1 USD per day
[13]. There is a well established correlation between a
nation's income inequality and the health of its popula-
tion (e.g., infant mortality rate and life expectancy) [14].
In fact, Guatemala is considered to have extreme income

inequality among Latin American countries and has the
third highest rate of infant mortality and third lowest life
expectancy among Latin American countries, behind Haiti
and Bolivia [15]. All ethnic groups are affected by poverty
in Guatemala (half of Guatemala's 13 million people live
in poverty, defined as less than $2 USD per day); however,
indigenous Guatemalans, who account for 38% of Guate-
mala's population, bear a relatively larger burden of the
country's poverty. Of Guatemalans living in poverty, 75%
(3.7 million people) are indigenous.
The Guatemalan healthcare system is composed of three
large sectors: The private sector, an autonomous social
security institute, and the public sector. The private sector
is subdivided into for-profit and nonprofit healthcare
organizations. The for-profit facilities include private hos-
pitals, clinics, pharmacies, and laboratories, all of which
essentially offer the full range of services available in most
industrialized countries. This sector is typically accessible
only to the wealthiest people of Guatemala. As of 2001,
less than 5% of the Guatemalan population was covered
by private insurance. In 2001, there were approximately
200 nonprofit nongovernmental organizations (NGOs)
in Guatemala engaging in health-related activities, 5% of
which were estimated to have nation-wide coverage [16].
According to the Swedish International Development
Cooperation Agency, there are 90 physicians per 100,000
population (9/10,000) in Guatemala [17], well below the
level of 25 physicians per 10,000 population considered
adequate by the World Health Organization (WHO) [18].
The Guatemalan Social Security Institute (IGSS) is a for-

mally autonomous institution financed by mandatory
contributions from workers and employers based on
wages, and it has its own network of services for delivering
care. IGSS provides coverage with a limited set of services
to formally employed workers, who tend to be urban
wage earners. As of 2001, 17% of the population was esti-
mated to be covered by IGSS [16].
The public sector is run by the Ministry of Public Health
and Social Welfare (MSPAS). This consists of a network of
government hospitals, health centers, and health posts,
which are staffed and maintained using public funds. As
of 2001, 54% of the population was estimated to be cov-
ered by the MSPAS network. According to the PAHO Pro-
file of Guatemalan Healthcare System [16], "the MSPAS
does not guarantee the delivery of a package of services,
nor do users tend to demand this as a right." As of 2001,
18.8% of Guatemalans were estimated not to have access
to any part of the healthcare system described here [16].
Although access to professional medical care is limited to
all ethnic groups in Guatemala, it is especially limited to
indigenous people [13]. See Table 1 for a summary of key
Guatemalan health indices.
It is worth noting that international efforts have been
made over the past 40 years to address the inequity in
access to healthcare among Guatemalans in the form of
numerous development strategies. As an example, in the
1970s, international organizations such as the WHO, the
United Nations International Children's Emergency Fund
(UNICEF), and the United States Agency for International
Development (USAID) financed a program whose goal

was to provide rural people with comprehensive primary
healthcare services. However, this program was aban-
doned less than a decade later in Guatemala. It has been
suggested that development programs such as these,
which filter a great deal of money through the govern-
ment, are frequently unsuccessful because they often do
not address the underlying causes of poverty which are
intimately related to poor health outcomes and may even
serve to paradoxically reinforce governmental corruption
and state suppression of the impoverished communities
for which the aid is intended [19].
Methods
The fieldwork for this paper was conducted in Guatemala
between October of 2006 and March of 2007, by two of
the authors (TG and HG). Both field investigators were US
medical students at the time with advanced but non-flu-
ent Spanish proficiency. Prior to the initiation of field-
work, the field investigators reviewed qualitative research
methods and Guatemalan history and culture. The study
was designed in consultation with anthropologists and
physicians with prior field experience in Guatemala, and
with extensive experience in qualitative research method-
ology.
In addition to the theoretical reasons mentioned above
for choosing Guatemala as the research country, the
researchers had multiple local contacts in the study area
around the town of Santiago Atitlan. Santiago sits on the
southern shore of Lake Atitlan, a large lake in the depart-
ment of Sololá. The closest facility with higher-level emer-
gency and surgical services is the government hospital in

the town of Sololá. Reaching Sololá requires a 30 minute
boat ride across the lake, followed by a 30 minute truck or
bus ride; the boats do not run after dark. Santiago was his-
torically a regional marketplace where indigenous farmers
and merchants from the southern shore of Lake Atitlan
and the lowlands to the south of the lake met to buy, sell,
and trade goods. Today, it continues to be an almost
exclusively indigenous region supported primarily by
agriculture and tourism.
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To acquire further context and contacts, the field investi-
gators spent their initial 2 months living and volunteering
in a small hospital under the supervision of fully trained
Guatemalan and US physicians. The hospital in Santiago
was established and is funded in large part by a US-based
NGO. It is run by a Guatemalan administrative team, and
supported by an executive committee made up of both
long-term expatriates and Guatemalans living in Santiago.
The hospital is staffed by paid Guatemalan physicians and
long-term foreign volunteer physicians, as well as a mix of
local and foreign volunteer nurses and medical assistants.
In addition to its long-term staff, the hospital relies on
short-term medical volunteers, including family physi-
cians, emergency physicians, pediatricians, obstetricians
and gynecologists, and general surgeons. After the initial
orientation phase in the hospital, the field investigators
continued to engage in hospital activities, in the spirit of
"participant observation." Participant observation, the
process of both observing local culture and practices and

participating directly in those activities, is an essential
component of ethnographic fieldwork where the
researcher is her/himself an instrument of data collection
[20].
The project was reviewed and approved by institutional
review board committees at the University of Colorado
Denver in the US and in Guatemala. Over the course of
this study, a total of 72 individuals were interviewed.
Informants were selected using "purposive sampling," a
sampling strategy in which the researchers focus "on
selecting information-rich cases whose study will illumi-
nate the questions under study" [21]. This necessarily
included a mix of Guatemalans and foreigners. Because
the principal aim of this study was to assess Guatemalan
perceptions of short-term volunteer work, the Guatema-
lans we interviewed are considered to be our primary
informants, and their statements are most heavily
weighted in the Results section of this paper. To under-
stand the perceptions of Guatemalans, we interviewed a
total of 23 Guatemalan healthcare providers (seventeen
physicians, two nurses, and four community health pro-
moters), five government health officials, and a group of
seven parents whose children were treated by short-term
medical volunteers. To understand the perceptions of
those providing short-term medical services we inter-
viewed 21 foreign medical providers including both
short-term volunteers (fourteen) and long-term expatri-
ates (seven), the latter having observed multiple short-
term volunteer groups. Finally, we interviewed sixteen
non-medical personnel working with a variety of NGOs or

health-related projects who, by virtue of their long-term
presence in the country, had the opportunity to observe
Table 1: Key health indices-Guatemala [37]
Life expectancy at birth in 2005
Male 65 (years)
Female 71
Maternal mortality rate in 2000 240 (per 100000 live births)
Probability of dying under 5 years of age
Overall (2005) 43 (per 1000 live births)
Lowest wealth quintile (1999) 77.6
Highest wealth quintile (1999) 39.3
Top five causes of death, all ages
Chronic obstructive pulmonary disease 53.3 (deaths/100000 population)
HIV/AIDS 49.0
Lower respiratory infection 39.3
Violence 37.1
Perinatal conditions 34.8
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short-term medical volunteers over an extended period
and were knowledgeable about the political, economic,
and cultural context of Guatemalan health and health-
care. As a group, the respondents varied in their level of
interaction with short-term medical volunteers, from
extensive to no direct contact. All, however, had knowl-
edge of the presence of short-term medical volunteers in
Guatemala and had opinions as to their role in the coun-
try.
Interviews were semi-structured, and typically lasted for
an hour, although some were significantly longer, and

some informants were interviewed on more than one
occasion. Most interviews included the two field investi-
gators and a single informant, although we also led two
small group interviews. Although we started with an inter-
view guide of questions that we hoped to address with dif-
ferent informants, this guide was used loosely to ensure
that information we thought would be significant was
included. Following the model of James Spradley [22],
these initial, exploratory interviews on a topic that has not
been previously addressed in the literature were tailored
to the experiences and expertise of our individual inform-
ants. Since interviews were not tape recorded and many
took place in Spanish followed by our translation into
English, many of the quotes are not verbatim, but rather
represent closely paraphrased and translated passages that
are our best attempt at capturing the idea the interviewee
was expressing. All informants were presented with an
information sheet in either English or Spanish which
explained the goals of the project and provided the
informant with written assurance of confidentiality. We
quote informants anonymously in this paper to protect
their confidentiality and privacy.
One obvious group of people whose perceptions would
be important to evaluate are the end-users (i.e. patients
treated by short term volunteer groups). However, in
designing this study, we elected not to focus on end-user
perceptions because it was felt that end-users in the midst
of receiving treatment from short-term medical teams
would be less likely to offer candid criticism of these
groups, especially to two US medical student interviewers.

Nevertheless, we did conduct one group interview with
seven parents of pediatric patients undergoing surgical
treatment by a short-term medical team from the US. In
this interview, we asked them why they had pursued care
from a foreign medical team rather than through a local
medical facility: their comments are briefly addressed in
the findings section that follows.
Shortly following each interview, the interviewers created
a document summarizing the relevant points made dur-
ing the interview. Direct quotes captured during the inter-
view by the note taker were also recorded in these
interview summaries. At the end of the field research
period, these summaries were uploaded into Atlas.ti 5.2
(Scientific Software Development GmbH, Berlin), a com-
puter software program which assists in the analysis of
qualitative data. The two field researchers simultaneously
reviewed each summary, labeling segments of text with
codes that corresponded to the themes (or topics) relevant
to the research questions. Once the summaries had been
coded and annotated, the interviewers then analyzed all
text segments coded under a given theme. These compila-
tions of text segments, coming from multiple interviews
but falling under a common theme, served as the basis for
each subsection presented in the results section of this
paper.
Results
Healthcare Needs of Guatemalan Communities
When informants were questioned about what they
believed to be the most pressing healthcare needs in Gua-
temala, a number of public health measures invariably

topped the list. The most commonly cited healthcare
needs included improved efforts at disease prevention
through health education and disease screening pro-
grams; improved public health infrastructure; and
improved access to primary medical care, particularly in
Guatemala's rural areas.
A number of informants focused on poverty as the key
determinant of the health disparities between the people
of wealthy and poor countries. One Guatemalan surgeon
working at a large national hospital stated the problem in
the following way:
[Foreign] surgical teams only work on the tip of the
iceberg when it comes to addressing the medical prob-
lems of this country. The problems of Guatemala –
corruption, lack of resources, lack of education – all
come from poverty. So poverty is the root of the prob-
lem, and surgery does not address poverty.
When the question of healthcare needs in Guatemala was
posed to a high-ranking official at the Ministry of Health
(MSPAS), he emphasized that the "primary problem in
Guatemala is a lack of public health infrastructure and
lack of primary care coverage due to a lack of financial
resources," further explaining that:
[Short-term medical work] does not, and cannot,
address these primary health issues of Guatemala. We
already have many surgeons and other physicians who
are well trained to take care of all problems common
in our country. The lack of healthcare in rural areas is
not due to a lack of physicians; it is due to a lack of
resources to provide clinics, hospitals, and supplies to

these areas.
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While none of our informants suggested that short-term
volunteer medical work could solve the country's most
pressing healthcare needs, there was nevertheless unani-
mous acknowledgement of the need for increased access
to curative medical care, especially for the poorest popu-
lations in Guatemala. Informants cited the public health-
care system (MSPAS system), as tending to be the most
accessible option to low-income populations in Guate-
mala. However, a Guatemalan primary care physician
working in a foreign-funded hospital explained the pit-
falls in the Guatemalan healthcare system:
Even though the national hospitals do not charge any-
thing for their services, preoperative studies are fre-
quently needed for scheduled surgeries. If the national
hospital does not have the equipment to do the stud-
ies, the patient must go to other places to get them and
at times has to pay a lot of money. So even though the
national hospital provides health services for free, the
patient frequently encounters costs that can prevent a
poor patient from receiving necessary treatment.
In addition, given the high levels of poverty discussed
above, simply traveling to a healthcare facility can be
financially burdensome for a significant portion of the
Guatemalan population. Compounding this problem is
the paucity of specialists outside of Guatemala City and
other larger cities. A physician who is an official at the
College of Physicians and Surgeons, stated that "Eighty

percent of Guatemala's specialists live and work in Guate-
mala City, so there is a vast shortage of specialists else-
where." In explaining the reasons for the lack of
Guatemalan specialists working in poor, rural areas, one
official at MSPAS stated that:
Physicians working within the public healthcare sys-
tem are underpaid the financial incentives to work in
a poor area do not exist. All of the specialists end up
living in big cities, sometimes splitting their work
between public and private practice.
In addition to the economic and geographic barriers to
accessing healthcare, language and discrimination were
also noted as significant impediments to care. One
informant is a Guatemalan employee of a US-funded
NGO that works closely with local community leaders in
rural villages to seek out patients who are in need of sur-
gery. This organization then coordinates the surgery, link-
ing patients with visiting surgical teams. If needed, they
also facilitate and help to pay for the transportation, trans-
lators (if the patients do not speak Spanish), accommoda-
tions, and food for the patient. This informant reflected
that many of the indigenous people (who tend to be those
who live in the most rural, poverty stricken areas) are
afraid to have surgery and often only speak an indigenous
language rather than Spanish, which prevents these
patients from entering into Guatemala's public healthcare
system. An indigenous Guatemalan whose son was being
aided by this US NGO had traveled 8 hours by bus with
her son who was awaiting hand surgery from a US short-
term surgical team. She stated that she felt physicians at

the national hospitals helped those with money first, and
then, if there is time, they would see the poor last.
Dependence on Foreign Providers
Over the course of our interviews, the issue of dependence
was frequently raised by both Guatemalans and foreign-
ers. One repeatedly cited criticism was that foreign medi-
cal projects remove or lessen the incentive for the
government to invest in healthcare for their own people.
A Guatemalan physician who works in a foreign-funded
hospital which is currently the only hospital in the area
offering 24-hour emergency and surgical/obstetrical care
is, along with a number of other physicians in the area,
petitioning the government to build a full-service, govern-
ment-run health center in his area. He explained that in
deciding where to invest money in improving healthcare
services, the government "only considers the number of
existing healthcare services already in the area, regardless
of the quality of services provided." Thus, the presence of
multiple NGO health projects in the area may actually
impede development of the area's public healthcare infra-
structure.
In addition to the potential for governmental dependence
on foreign medical aid, many informants described the
problem of patient reliance on free medical and/or surgi-
cal care provided by short-term volunteers. A Guatemalan
administrator working in a local NGO which provides
reproductive health services throughout Guatemala,
expressed her concerns regarding free care provided by
foreign medical groups:
Patients get used to the free care and end up waiting

for the next group to arrive to give them free care rather
than seeking out ways in which they can help them-
selves. What will happen when all the NGOs leave?
The people won't know how to go about finding a way
to get care.
Similar sentiments were noted by an American surgeon
and head of an NGO in Guatemala, who stated, "If a vol-
unteer group provides free healthcare, the community can
become spoiled and end up relying on that service rather
than on the permanent [government-run] system which
already exists."
Patient Selection and Payment Systems
When our informants were questioned about ways in
which dependence on foreign aid could potentially be
Globalization and Health 2009, 5:4 />Page 7 of 13
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avoided, appropriate patient selection and attention to
the payment system were most frequently mentioned.
When discussing the issue of patient selection, there was
almost universal agreement between both Guatemalans
and foreigners that short-term volunteer groups should
focus their services on the populations who are most in-
need. The most frequently cited challenge to shot-term
medical volunteer work was the task of reaching the
patients who truly cannot afford other options for medi-
cal attention. We spoke with a Guatemalan physician
working in a clinic that was hosting a North American
short-term surgical group. He expressed his concern that
the aid provided by volunteers may not actually be reach-
ing the poorest people in Guatemala and emphasized that

if patients who can afford to pay for their own private care
receive free care from foreign volunteer groups, those vol-
unteer groups end up competing with the private Guate-
malan physicians (who could perform the same surgeries,
but for a fee) for patients. He went on to describe the chal-
lenge of trying to suggest to the North American group
that they perform a financial evaluation of all patients in
order to help target those who truly cannot afford to pay
for surgery. He stated that he sensed that the North Amer-
icans "seem to perceive everyone in Guatemala to be poor,
and therefore do not think it is important to do a socioe-
conomic evaluation."
Informants' opinions on which payment system should
be used by short-term medical groups were varied. One
head coordinator of a short-term medical volunteer group
stated that their group provided "completely free surgical
care to every patient without an evaluation of their ability
to pay." A number of informants criticized this form of
care, suggesting that it becomes "detrimental to society"
by causing disinvestment in healthcare by the government
to take care of their own population, dependence on out-
side aid, and competition with the existing healthcare sys-
tem.
A few informants were of the opinion that short-term
medical volunteer work should be free to those patients
who cannot afford care in Guatemala. One foreign-born
surgeon, who has been operating full-time in poor coun-
tries for nearly 20 years, stated that he provides com-
pletely free surgery to the "poorest of the poor" through a
private foundation. He described why he chooses to do

this in the following way:
Last year, I did over 5000 free surgeries for the poor
around the world and if my patients would have had
to pay for this care, I probably would have done half
that number of surgeries. The poorest patients do not
have the resources even to be able to afford the trans-
portation, accommodation and food while they are in
the hospital, let alone the surgical and medical
care What's the definition of charity if it's not free?
In addition, two out of the four health promoters working
in rural, poverty-stricken areas described the free care pro-
vided by short-term medical volunteers as one of the
greatest benefits to their patients. One health promoter
stated, "If [patients] have to pay for their care, some are so
poor that they will have to choose between paying for
food and paying for their medical care."
Of the 20 informants who discussed the issue of payment
directly, fourteen believed that all patients should pay
something for their treatment. Most believed that when
patients were asked to pay for their treatment, they were
in a better position to feel as though they had ownership
of their own care, rather than being passive informants in
that care. A leader of a US NGO that seeks out patients in
rural areas in need of surgical care always has the patient
pay something for this service (often it is only a few quet-
zals – equivalent to less than $1 USD). He described his
reasoning in the following way:
I remember talking to a couple of patients who came
back from a free surgical [short-term medical volun-
teer group] who were dissatisfied with their care.

When pressed for why they were dissatisfied, they said
the facility made them clean up their own area, or they
didn't have tortillas – small, irrelevant reasons for
their dissatisfaction with their care. I have never had
that experience with patients who have to pay some-
thing for their care.
Another administrator at a Guatemalan NGO echoed
these sentiments by saying, "Even the poorest people in
the country can find five quetzals. The point isn't to cover
the cost of the care. Rather, the point is to get people to
take more responsibility for their own care."
Nearly all of the informants who believed in asking for
payment from patients (including Guatemalan healthcare
providers, health authorities, community members, and
foreigners) suggested using a sliding scale system of pay-
ment, in which the amount patients are asked to pay is
based on a careful socioeconomic screen performed by
social workers and/or leaders of the patient's community,
who are in the best position to know what the patient can
actually afford to pay. Again, the informants emphasized
that the payments should never jeopardize the patients'
ability to obtain health care.
Burden on Host Organization/Community
Another major theme frequently discussed by the inform-
ants was that short-term medical volunteers have the
potential to be quite burdensome (both financially and in
Globalization and Health 2009, 5:4 />Page 8 of 13
(page number not for citation purposes)
terms of personnel time) for host organizations and com-
munities in Guatemala. It should be noted that nearly

every Guatemalan interviewee expressed appreciation for
the service that visiting teams provided to their communi-
ties and many acknowledged the personal sacrifices that
individual volunteers made in order to provide these serv-
ices. Nevertheless, there was also a great deal of discussion
about how this type of work can become financially bur-
densome for the host organization. One Guatemalan
project coordinator of short-term medical volunteers
expressed that he felt he was "half project coordinator and
half tour guide. I have to arrange transportation, accom-
modation, food, and translators for all of the volunteers."
Many informants noted that a big disadvantage to short-
term medical volunteer work is the strain on local person-
nel time when the volunteers did not know the language
or were unfamiliar with the clinic setting. A project coor-
dinator of a US NGO stated that, "When the volunteer
doesn't speak the language, misunderstandings can occur
and cause big problems, not only for patients, but also for
local staff who work with the volunteers."
Some short-term medical volunteer organizations have
tried to combat this problem by asking their volunteers to
pay for their own expenses. The head of an NGO which
regularly organizes surgical short-term medical volunteer
work in a private hospital in Guatemala, expressed the fol-
lowing thoughts:
We get into trouble when physicians just bring their
hands. We ask all of our volunteers to cover their own
expenses, such as travel, lodging, and food. We also
cover the cost of each surgery, including supplies and
electricity in the operating rooms, and to offset the

financial burden on the hospital of providing follow-
up care, our visiting groups make a donation to the
hospital for each patient they operate on. We under-
stand that it is very expensive for any facility to host
short-term volunteers.
Numerous informants suggested that it is best to limit the
number of people on a visiting medical team to only
those who are necessary, as large groups tend to get in the
way of the regular operations at host facilities and end up
being a rather large burden. As an extreme example, a phy-
sician who has worked on various medical aid projects
around the world, told us of a visiting medical team from
the US which brought 78 people, including surgeons, pri-
mary care physicians, nurses, cooks and translators. He
continued:
Guatemala already has doctors, nurses, cooks and
translators. So, it would be better to bring the special-
ists that may be needed and then utilize as many in-
country personnel as possible to carry out the mission.
In that way, you are wasting less money, strengthening
the country's healthcare resources, helping the coun-
try's economy, and increasing the quality of care.
Coordination
Many Guatemalan informants talked about a level of arro-
gance or elitism that they often see in visiting medical pro-
fessionals. Most of these informants noted that when
foreign providers work in coordination with the local
healthcare providers, it reflects an acknowledgement that
the local providers are competent. Working in isolation
from the surrounding medical community was perceived

to reflect the opposite sentiment. Furthermore, the respect
shown to local providers by working alongside them is
also perceived to be visible by the local patient popula-
tion, which has a positive impact on the local provider's
relationship with their community.
Some Guatemalan physicians described their frustration
with visiting medical teams who work in isolation from
the local medical community. A Guatemalan surgeon
who works in a private clinic as well as a national hospital
poignantly stated:
Guatemalan patients, especially those with less educa-
tion, tend to put more faith in a blonde haired, blue
eyed, white skinned foreign physician than their own
Guatemalan physicians. These foreigners show up
with their shiny new equipment and do their free sur-
geries without ever working with any of [the Guatema-
lan physicians]. US doctors come to Guatemala and
practice medicine when and where they want. Guate-
malan doctors may have a hard time even entering the
US, let alone being able to practice medicine there. US
physicians are not superior to Guatemalans. I am per-
fectly capable of taking care of my own people.
In discussing the utility of short-term medical volunteer
work with the co-founder of a successful NGO that organ-
izes US surgical teams to perform surgeries in Guatemala,
he said, "Short-term volunteer work can be completely
effective if it's attached to a long-term program." The
importance of short-term medical volunteers coordinat-
ing their activities with groups that have a long-term pres-
ence in Guatemala was by far the most frequent

recommendation made by our informants. In fact, it was
often more of a demand than a recommendation, with
some informants commenting that short-term medical
volunteer work that is not coordinated with a long-term
presence is "the worst kind of care," or that those short-
term medical volunteers "might as well stay home."
When describing the benefits of coordination, one long-
term foreign volunteer noted that the local healthcare pro-
Globalization and Health 2009, 5:4 />Page 9 of 13
(page number not for citation purposes)
vider could offer the short-term medical volunteer knowl-
edge of resources, customs, and opportunities available to
the local population. In addition, by coordinating with a
long-term presence well in advance, many informants
pointed out that the local contact is able to recruit patients
for the volunteer group to see.
Additionally, coordination with a local, long-term pres-
ence is a legal requirement in Guatemala. In order for vis-
iting healthcare providers to practice medicine in
Guatemala, they are required to register with the College
of Physicians and Surgeons (Colegio de Médicos y Ciru-
janos), providing evidence of credentials and a Guatema-
lan physician contact. Nevertheless, a number of
Guatemalan health authorities and healthcare providers
expressed concern that many groups of foreigners practice
medicine in Guatemala without communication or coor-
dination with the local healthcare system.
Meeting the Needs of the Community
Groups that do not work in coordination with a long-term
presence frequently provide services that do not match the

needs of the community. Many informants talked about
"de-worming campaigns" in areas without clean drinking
water sources; groups that provided free eye glasses with-
out an eye exam; or groups that indiscriminately handed
out vitamins as examples of particularly misguided inter-
ventions which reflect the lack of coordination and con-
sultation with the local healthcare community.
Another detrimental effect of groups who practice in iso-
lation is that services already provided by the Guatemalan
community end up being duplicated by the volunteers.
For example, we spoke with a Guatemalan physician
working at a government health post in a community that
was recently devastated by a natural disaster. His area reg-
ularly receives many foreign medical aid groups; however,
"very few have actually come [to his health post] to ask
about what is needed." He further described the problems
with this lack of communication, citing an example of a
short-term medical volunteer group who saw patients
over a weekend and provided medications without any
records or understandable explanations to the patients of
why they needed the medication. He said those same
patients came to his health post the following week, una-
ble to explain what was done and why they were taking
medication, forcing him to repeat their exams without any
benefit to the patient or the system.
Many informants pointed out that at the very least, it is
important to be in contact with local providers to ensure
that what the volunteers are doing is actually needed and
desired in the community. As one long-term foreign vol-
unteer stated, "First understand if the people who you

plan to help actually want it."
Follow-Up Care
Follow-up care frequently came up in the context of why
coordination with a long-term presence is important. As
one interviewee pointed out, "Most problems take longer
than one week to fix – without continuity, the care is not
complete." In addition, many Guatemalan healthcare
providers expressed willingness to provide the follow-up
care to patients with whom they had personal contact, but
stated that providing follow-up care to patients with
whom they were unfamiliar could be problematic. Many
informants suggested that one way to minimize incom-
plete care in the surgical field is to provide a record of
what was done and why (in the appropriate language) to
each patient, to the facility in which the surgery took
place, and to the physician who will be responsible for the
follow-up care.
One nonprofit private hospital was often cited as being
particularly excellent at providing follow-up care. This
hospital, through a small number of international NGOs
with which they coordinate, hosted surgical teams from
North America and Europe year-round and provided very
low-cost surgeries to pre-screened patients who were in
need. They involved Guatemalan surgeons and support
staff in the surgery, and had patients return to that same
hospital (where each patient's records were kept) for their
follow-up care. They also hired a Guatemalan surgeon
whose primary responsibility was to take care of post-
operative patients and complications which arose from
surgeries performed by foreign volunteers.

Resource and Information Sharing
Surprisingly, a number of the foreign volunteers were
quick to point out that the benefits of short-term medical
volunteer work may be greatest for the volunteers them-
selves. However, the majority of our Guatemalan inform-
ants (including healthcare providers, health authorities,
and Guatemalans working on other health projects) as
well as the long-term foreign volunteers also emphasized
the fact that if coordination exists between visiting and
local healthcare providers, these short-term medical inter-
ventions can be a positive experience for the local provid-
ers as well. Many Guatemalan informants described the
educational opportunities for both sides when visiting
teams work together with the Guatemalan providers. Oth-
ers suggested educational exchanges between US and Gua-
temalan medical schools and sending the Guatemalan
physicians to educational conferences as ways to provide
mutually beneficial interactions.
The Guatemalan informants often cited the donation of
equipment, medications, and supplies as one of the great-
est benefits of short-term medical volunteer work. A Gua-
temalan ophthalmologist in private practice pointed out
that:
Globalization and Health 2009, 5:4 />Page 10 of 13
(page number not for citation purposes)
There is a cost for the local ophthalmologist to provide
follow-up care to patients who cannot pay for it, so
there needs to be a reciprocal benefit to the relation-
ship. Money is not the solution – that disappears and
doesn't get to the patients. But, if volunteers leave

something behind for the local physician, such as
equipment, medications, operative instruments, or
supplies that the physician could continue using when
the volunteer group leaves, that benefits us and our
patients.
It was often stated that donations amplify the impact of
short-term medical volunteer work, as they improve the
quality of services offered even after the volunteers are no
longer present. However, the recipients of these donations
often talked about the vast amount of expired medica-
tions they receive, which amount to what one interviewee
referred to as "trash" that must be sorted through and dis-
posed of, thus wasting valuable staff time. The argument
that expired medications were "better than nothing" was
not supported by our informants, as one interviewee com-
mented, "If the medications aren't fit for human con-
sumption in the US, why should they be fit for human
consumption in a poor country?"
Quality of Care
Many of the foreign volunteers and volunteer coordina-
tors focused on the issue of quality of care when practicing
outside of one's own country. They talked about striving
to provide the same quality of care as one would at home
and working first and foremost out of responsibility and
respect for the patient. As one long-term volunteer put it,
"Always keep in mind that you are there to provide the
best possible care for the patient – do things because the
patient needs them, not for your own experience." They
emphasized using good judgment in making medical
decisions, including conservative patient selection for sur-

gical cases. Many volunteers also discussed the impor-
tance of knowing your limits as a visiting physician and
restricting your work to cases that are within one's techni-
cal limits and that fit the resources of the setting.
Along the lines of professional judgment, many inform-
ants (both Guatemalan and foreign) expressed concerns
that some short-term medical volunteer groups may be
trying to see too many patients per day at the expense of
quality of care to the patients. Informants often worried
that when volunteers focused on the number of patients
seen per day, rates of complications increased, misdiag-
noses and inappropriate treatment abounded, and patient
education plummeted. In addition, the majority of our
informants believed that religious and political discussion
should be kept separate from the provision of patient care.
Discussion
Our study, although small in scope, is one of the first to
systematically and critically examine the effects of short-
term medical volunteer work. All major thematic areas in
our results underline the challenges of outside groups
working as equal partners. Is it paternalism or coopera-
tion? Is it charity or aid? Is it experimentation or quality
care? Have all stakeholders been properly identified? Let
us say that a recipient community has been appropriately
consulted and involved to develop the most suitable inter-
vention with strong community ownership. Omitting
other healthcare providers, organizations, and the Minis-
try of Health may nevertheless jeopardize the long-term
success and sustainability of any effort. The very real
power and wealth differential between short-term medi-

cal groups and their host communities make trust, under-
standing, and true partnership difficult.
The complex nature of feelings toward short-term medical
volunteer groups in our study parallel the often nuanced
and contradictory feelings toward the US and industrial-
ized countries. Guatemalans have particular reason to be
suspicious of the US: The US-based United Fruit Com-
pany and the Central Intelligence Agency coordinated the
overthrow of democratically elected Guatemalan presi-
dent Jacobo Arbenz in the early 1950s and brought an end
to important social progress in Guatemala [23,24]. This
US-backed "regime change" ushered in a 40 year period of
state-sponsored terror, which resulted in up to 200,000
deaths and disappearances, and the displacement of over
1 million Guatemalan people [24-26].
The challenges facing foreign providers do not negate the
potential benefits of external assistance. Despite its rank-
ing as a middle income country, Guatemala "holds some
of the poorest health records in the Americas" and "holds
the third-lowest position in the Americas in percentage of
GDP dedicated to both private and public health care –
4.4%" [27]. Because of widespread poverty in rural areas
and poor compensation for physicians in the public
healthcare system, there is little incentive for Guatemalan
physicians to work in poor communities. Cuba's medical
assistance program helps bridge the gap, in a manner that
is directly integrated into Guatemala's healthcare system.
In 2002, 514 Cuban doctors were working in rural areas
of Guatemala to staff public health clinics run by the Sis-
tema Integral de Atencion de Salud (SIAS), the national

health care system established under President Alvaro
Arzu (1996–2000) that increased coverage in rural areas
by 90% [27]. Cuban healthcare providers often stay for
two years or more, have language on their side, and lack
some of the baggage of health professionals from the US.
Short-term volunteer groups may yet identify a framework
to contribute meaningfully. Very few have attempted to
Globalization and Health 2009, 5:4 />Page 11 of 13
(page number not for citation purposes)
identify guidelines that would make short-term medical
work more effective, despite its limitations. Suchdev et al
listed seven guiding principles from their experience oper-
ating short-term medical groups out of the University of
Washington: A clearly defined mission, close collabora-
tion with the recipient community and its institutions, a
focus on sustainability, education for the short-term team
and the community, service by addressing true health
needs, teamwork among short-term volunteers, and rigor-
ous program evaluation [28]. Much of the remainder of
the existing literature rightfully draws attention to the pit-
falls of short-term volunteer work, but has little to offer in
terms of a generalizable solution [1-7]. To date, it appears
that more scholarly attention has been directed to the
educational, ethical and practical issues facing medical
students on international electives [29-33]. The situation
of these medical students is similar in many ways to that
of short-term medical volunteers; they are often poorly
prepared, poorly connected, and tempted to practice out-
side of their scope of competencies. Those unprepared
will repeat the same mistakes, as for example, in Paul

Farmer's words, "conflate poverty with culture" [34]:
Attributing differences in healthcare practices and deci-
sions to different cultural beliefs, rather than to lack of
resources and basic services.
According to our results, recipient communities may per-
ceive very tangible benefits from short-term volunteer
groups: Free or discounted care, improved access to
healthcare overall, access to highly-trained specialists, and
access to procedures not always possible within the local
infrastructure. Local providers enjoy exchanging experi-
ences and knowledge with foreign visitors, and appreciate
the influx of supplies that accompany volunteer groups.
On the negative side, it appears some of the least sophis-
ticated groups offer services or treatment that are seen to
be at best duplicative, and at worst, harmful. For example,
though some drugs may remain effective 1–2 years past
their expiration date, the perception of harm may arise
from using drugs that are no longer considered safe, legal,
or effective in the US. Similarly, a surgical group not plan-
ning for appropriate local follow-up could also be seen as
acting recklessly and creating the potential for harm. Such
issues may be easily solved with proper planning and sup-
plies. On the other hand, many situations described by
our respondents do not present the opportunity for an
easy fix. Well-intentioned, well-prepared groups provide
services that may help many but may harm others though
unforeseen externalities. For example, free care from out-
siders improves access in the short-run, but may under-
mine local healthcare providers, and in the long-run may
reduce access: The government might close public clinics

with patient volumes that are dropping, and private phy-
sicians might leave for areas without competitors provid-
ing free care. This could only further increase the
dependence on external assistance. Significant externali-
ties in medical assistance are not unique to short-term
medical volunteer groups. Garrett describes "Dutch Dis-
ease" in developing countries, where large expertly-
planned and externally-funded vertical health programs
draw human and material resources away from primary
care, and from other vital sectors of the economy [35].
The debate over free care, raised by some of our respond-
ents, has a long history and continues vigorously in the
development circles [36,37]. Some believe that patients
and communities will only truly take ownership of and
responsibility for their healthcare if they have to pay for it.
Other groups, such as Partners in Health http://
www.pih.org/what/PIHmodel.html argue that healthcare
is a right and that any fee is a barrier to health care access
for the poor [34].
Our study has several limitations: 1) It relies on targeted
expert informants rather than on the direct recipients of
medical care from short-term medical volunteers; 2) It
examines only one small part of the world, thus making
generalizations difficult; 3) It lacks external reference
points, given the scarcity of research on short-term medi-
cal work mentioned; and 4) It used field investigators who
were outsiders: American medical students who were non-
native Spanish speakers. Though there is little formal
research with which to compare our results, the issues
raised by authors previously cited [1-7] are similar across

continents and countries, thus mitigating limitations 2
and 3. Regarding limitation 4, it would appear from their
responses that many informants had no difficulty being
frank and open with the field investigators. Language bar-
riers may indeed have impeded understanding of subtle
nuances; however, the concordance of responses, as well
as their complexity, would suggest, at a minimum, ade-
quate comprehension.
The possibilities for future research in short-term medical
work abound: With regard to the perceptions of Guatema-
lan healthcare providers and authorities to short-term vol-
unteer work, a more in-depth analysis of how informants'
place in the Guatemalan healthcare system and in the glo-
bal political economy of healthcare (e.g., links to foreign
medical schools, to local, regional, and international
NGOs, national and international professional associa-
tions, and religious organizations) would further illumi-
nate the complex gradients of dependence and the flow of
resources. With regard to short-term medical volunteers,
surveys and group and individual interviews could assess
their attitudes toward and perceptions of the countries in
which they have worked both before and after service to
improve preparation for volunteer work and design pro-
grams that build more truly reciprocal relationships. With
regard to recipients of healthcare from short-term medical
Globalization and Health 2009, 5:4 />Page 12 of 13
(page number not for citation purposes)
volunteer groups, future studies should seek to under-
stand who pursues care from short-term medical volun-
teers, why, and under what circumstances. Are there

perceived or actual differences in quality or type of care?
Are patients and their families satisfied with their care?
Does seeking and obtaining care from foreign providers
carry different social meanings, e.g., greater status, than
care from Guatemalan providers or state-run clinics?
Finally, it is our hope that this paper will stimulate studies
into the economic, political, and health outcomes of
short-term volunteer programs to critically assess their
quality and effectiveness. What is the effect of the concen-
tration of such services on the government investment in
healthcare infrastructure and services in those areas? Do
free or very low cost services provided by short-term vol-
unteers truly draw patients away from private practition-
ers or state services? Are outcomes for procedures (e.g.,
cataract removal) or conditions (e.g., diabetes) different
when care is provided by the regular healthcare system
versus by short-term medical volunteers?
Conclusion
The perceived impact of short-term medical volunteer
projects in Guatemala is highly variable and dependent
upon the individual project and the perspective of the
observer. In this exploratory study, certain project effects
were repeatedly identified as being either positive, such as
improved access for the underserved, or negative, such as
drain on local resources. Other responses highlighted the
complex consequences of short-term medical volunteer
work, through unforeseen externalities on the healthcare
system. These findings have direct implications for any-
one involved in the planning and execution of short-term
medical volunteer projects, including local and foreign

medical team members, project planners and coordina-
tors, and health authorities. Most importantly, this study
suggests avenues for future study and evaluation of the
impact of short-term medical volunteer programs on local
health care services.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
HG and TG carried out all interviews and data analysis
and interpretation. All authors contributed to the concep-
tion and design of the study, all authors were involved
with drafting and critical revisions of the manuscript, and
all authors read and approved the final manuscript.
Acknowledgements
The fieldwork phase of this study was funded by the William Robinson/
Peter Durst scholarship for research in international health, and by the Wil-
derness Medical Society's Charles S. Houston research award. Article-
processing charges were covered by the Division of Emergency Medicine
and the Department of Health and Behavioral Sciences at the University of
Colorado Denver.
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